ORTHODONTIC INSURANCE (IF APPLICABLE):
Please check if the patient has a history of the following medical conditions:
Please check if the patient has, or ever had, any of the following habits?
I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status.
I hereby authorize this office to perform an orthodontic evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate orthodontic treatment on the above-named patient.
I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.
If you are experiencing a dental emergency, contact us immediately, and we’ll work to provide the care you need.
Your teeth can be straightened without anyone ever knowing you’re receiving orthodontic care at all! Click here to learn more.
Looking for a way to touch up or completely transform your smile? Schedule a visit with us to learn what we can do for you!
Whether it’s just a cleaning or more complex dental work, we can provide high-quality service to all members of your family!